I appreciate the work done for the PBS Frontline program on the risks of dementia care in assisted living. Facilities that care for elders with frailty and dementia must have training to address the special needs of these elders. These needs include the possibility of serious illness presenting as minor behavioral changes, the inability of the person to communicate, or recognizing the complications of illness or conditions such as heart attack, pneumonia, back pain or constipation. As a geriatrician who makes house calls, primarily with patients with dementia and agitation in the San Francisco Bay Area, I have seen poor care and have seen amazing care in facilities and at home. I have also worked with the San Francisco Forensic Elder Abuse Center with the District Attorney and with Adult Protective Services on abuse cases committed by individuals and facilities. I have also worked with CANHR (California Advocates for Nursing Home Reform) consulting on challenging patient’s rights, and participated on a panel discussing the use (and abuse) of Anti-Psychotic Medications.
I do agree that some facilities are poorly run, and profit is the major goal. I have also seen many facilities that have been a lifesaver for an elder unable to live any longer alone, who may have kicked out the caregivers at home, or instances where the family cannot care for the elder at home any longer. The choice of care at home, whether assisted living, board and care or nursing home is complex and must be an individual decision for every elder and their family. Each choice is the correct one depending on the particular circumstances. As a society, we need to explore further the challenges of the family caring for elders with dementia and especially those elders with behavioral problems. My greatest fear is that the outcome of shining a light on assisted living that is only negative is that most facilities will not take those with dementia who have the worst behavior.

If a residential community cannot provide the proper care to allow a resident to remain safe in the community, it is true that the resident should not reside in that facility. But where do they go when they fail at several facilities? I fear a common approach is simply to prescribe drugs such as Haldol and Ativan until they are so medicated that they don’t cause trouble any longer.

A nursing home is not likely a better fit in that few have special dementia behavioral units that address the behavioral needs of these elders. I receive calls and patients sent from the San Joaquin Valley in Central California to address their behavior, since no local facilities will take the person in question. I have seen hospitals telling frail elderly wives to take their husbands home, who were admitted for combativeness. This is necessary because no nursing home will accept the patients who spent their hospital time in restraints. As a culture, we have a long way to go to care for these elders.

Full disclosure; I am a medical director at Silverado in Belmont, CA; a dementia assisted living facility. We work constantly to address the needs of the residents and help them enjoy their days. However, I also have seen life giving care at other facilities and from high quality home care. It does take a village.